TA and treatment planning for psychotherapists

[email protected] www.ta-psychotherapy.co.uk @ytcitraining Treatment Planning- models and a new picture… Dave Spenceley TSTA – edited March 2017


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Treatment planning a non-linear approach to treatment planning and a review of classical treatment plans – Also notes on contracting in TA and Dave’s two stages of psychotherapy

Dave Spenceley – March 2016

The co-created therapeutic relationship provides the space in which treatment takes place, specific techniques are used to enhance the effectiveness in the therapeutic empathic relationship, these approaches can only be effective within a healing therapeutic alliance.

mailto:[email protected]

http://www.ta-psychotherapy.co.uk/





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Fanita English – TAJ 1997: “A good therapist is a good technician, an artist, a loving human being, and an individual who values self-examination about her own motives and behaviour. When I first thought of these attributes, I put "loving human being" as the first one, in that a loving therapist can concern herself with others and be of help just by radiating a special kind of warmth which attracts even mistrustful people. But there's the catch! And this is why I list technique and art ahead of lovingness when I discuss a therapist rather than a person. To be a loving human being is a prerequisite for a therapist. However, without solid technique and a certain artistic flair, a therapist can be engulfed by the problems of her patients, and she can end up crucified or devoured by their cannibalistic needs when they seek ways to fill a certain emptiness within themselves.” Fanita English: “What is a Good Therapist” TAJ: April 1997 Being a good technician requires that the therapist has a strategy for what lies ahead, this strategy acts as a guide in the difficult and obscure journey ahead… Not like a detailed OS map, you do not need to know where each wall and contour line is however you do need to have a general sense of how to cross the difficult terrain safely. Most of the psychotherapy guides are written as if they are linear going in a straight line however experience shows that it is often the case that the stages over lap and can be revisited as each new area is approached and dealt with in the therapeutic journey.

Redecision / script change cannot take place without the relationship and yet without making these changes we are at risk of creating a cosy relationship which sounds like what Berne warned about when he described the game of psychiatry:

Berne's: Adult decision to put a different and new show on the road.

The Goulding's: A redecision within the Child ego state originally the Goulding’s suggested this occurred within one session – however it is likely that the process of script change / redecision evolves over time.

Two Phases of therapy: Light from one perspective is a wave from another perspective light is a particle. I use this to describe two phases of psychotherapy. Psychotherapy is like a particle when we deal with specific problems, using techniques and creating strategies to

deal with these problems of life and relationship. Psychotherapy is like a wave, two people or a group of people forming a wave of movement and intensity in

relational experiences which in turn leads to change in each individual. My approach to the therapeutic endeavour: During the first session I always say something along the lines of the following to my clients: First: I am very interested in getting to know you, listening carefully to your story, seeking to understand the reasons why you have decided to come for therapy with me, and why now. During the early stages of the work I am interested to explore with you what it is you are wishing to change in your life, and how you would like to be after therapy has finished. If there is a particular problem that has brought you to therapy, then the initial goal will be for you to find strategies in order to deal effectively with that problem or problems. For example, if you are afraid of going shopping we will be looking for strategies which will enable you to be comfortable in yourself while going shopping.

Theoretically I think of this first stage of therapy as exploring and resolving 1st degree impasse(s), strengthening the Adult ego state boundaries.

Berne described this as gaining social control and symptom relief.







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Secondly: I am very interested in how you are in your life: Your motivations, fantasies and desires, how you live and why. How you think, feel and how you make decisions about what you do and don’t do. I will be noticing with you the way in which your life outside the therapy room is reflected in how you are in your relationship and work with me. As the therapy progresses how you are in our relationship will increasingly become the focus of our explorations and the psychotherapeutic work. The goal is for you to make lasting changes in your life which will enable you to manage and contain your future life.

Theoretically this is understood as exploring and resolving embodied 2nd and 3rd degree impasses. Berne described this as psychoanalytic / script cure. This phase of psychotherapy is focussed on deconfusion of the Child ego state and constructing a healthy

Parent ego state. Rather than describing this as being script free as Berne would have done I understand the process as

creating a healthy script narrative to guide you in your life. As the core competencies of TA say so well: Healing the hurt of the past in order to live fully in the present.

During both phases I might well use specific techniques and approaches from the TA toolkit – however their goal is always to enhance the empathically attuned exploration of your experience. I use the traditional Chinese metaphor: “The first phase is ensuring you have a fish and so you don’t starve today. The second phase is about learning all you can about how to catch fish so you will never starve.” The difference is that in the first phase it is going to the local shop to buy a fish; while the second phase is building a fishing boat and learning all about fishing. Including where the fish live, understanding the hidden currents, the life of the deep as well as learning to captain the fishing boat; Which makes for a long term project!” I normally conclude by providing the transferrentially inviting statements that I confidently expect that we can deal with the first phase relatively quickly and that according to research clients can expect to achieve these socially observable changes within the first 12 sessions, and often more quickly. While the second phase will take as long as we need. Finally, you might make some startling / disturbing changes in your life…” TA models The main frame I use is my understanding of the structural model of ego states and my own development of impasse theory which I describe later in this article. I have found no better way of understanding and analysing the developing intra-psychic process as it is enacted by clients and psychotherapists in their co-created experience in the transferrential process. The first phase of TA psychotherapy: Leading to social change and strategies for daily living. That is dealing with 1st degree impasses. I believe it is very important to honour the clients desire for change… invariably a client enters therapy because of disturbance and stress in their lives, finding ways of managing / containing their lives safely and effectively is their primary concern, they do not need to wait for a long term unfolding of and resolution of the transference their therapy in order to do this. Indeed many clients will not have the desire or motivation needed to engage in the second phase of psychotherapy. Often the idealised transference maintains and contributes to the hope and belief that the therapist can be used to find the first level of healing. If the client leaves therapy after successfully making the change they desire in the first phase of psychotherapy it is very likely that their idealisation of the therapist will be heightened and remain unresolved. (Indeed they are likely to be source of future referrals to the wonderful and effective therapist!) Steps to treatment: a. The first priority is to establish and maintain a therapeutic contract and therapeutic alliance… while also paying

close attention to the client`s transferrential process during the work. On occasions it will make sense to use this







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transferrential process early in the first phase of work, sometimes naming the process at other times without overtly naming the process.

b. During the first phase the emphasis is on “classical” TA approaches such as transactional analysis, game theory, script analysis, racket analysis with the goals of:

Understanding and then finding an impasse resolution. Strengthening the Adult ego state boundaries so that the client can function effectively in their daily life. It is likely that this wok may take the form the client making a redecision in any of their ego states… In the

first phase of treatment this is more likely to be a redecision as described by Berne… The client understands the impasse and the solution in the here and now… and makes a decision in the Adult ego state.

c. Once the initial presenting problem is effectively dealt with then it is important to review with the client their contract… do they wish to continue on to the second phase of the work?

The secondary phase of TA psychotherapy: The goal of this phase is to work with the client’s unconscious process leading to lasting script change. My understanding is this is dealing with 2nd and 3rd degree impasses which I also refer to as deconfusion of both the Child and Parent ego states while continuing the task of strengthening the Adult ego state boundary. The therapeutic relationship becomes the focus, increasingly fewer techniques are used in the sessions and discussions of the client’s activity outside of the room becomes less important… over time the emphasis in the therapeutic work shifts so that the therapeutic relationship itself is the focus. Working in and through the transference will lead to many transformational experiences. The Goal during this phase is for the client to make new meanings for him / herself and in this way for their new lives to take shape and direction. Often clients find difficulty articulating the issues dealt with in the second phase, they are dealing with their core experience of themselves – their beliefs of themselves, others and life… which often only find expression through nonverbal unconscious transference expressions, dreams, fantasies and somatic experiences. Following the work, the client may well find it just as difficult to articulate their new self. However, their unconscious transference expressions, dreams, fantasies and somatic experiences will change, often dramatically. Their beliefs about themselves, others and life will also be changing. Steps to treatment: The therapeutic relationship which was established in the first phase becomes the container for the ongoing psychotherapeutic work. 1) Depending upon the style of therapeutic relationship and working that evolves the actual process in the therapy

room will take a variety of forms. We know that any one technique does not prove to be better than any other in creating transformational experiences.

2) At times this may look like the psycho-dynamic / analytic approach. 3) At times it may involve passionate / energetic body work 4) At other times this may take the form of redecisions which correspond to the how the Goulding’s described

redecision in the Child ego state or those of described by Mellor and then later Erskine and Moursund that take place in the Parent ego state.

5) The second level of impasse will be experienced through unconscious expressions of the transference, somatic / body experiences, dreams and fantasies. The client will be making cognitive sense of their experiences through limited, magical thinking which maintains their script representation of life, of others and of their own place in the world.

6) The third degree level of impasse will be experienced none verbally, and so can only be understood and made meaning of through unconscious expressions of transference, body experiences and dreams…

7) These unconscious expressions of the clients are welcomed and worked with… leading to deconfusion of the Child and Parent ego states.

8) Termination of the therapeutic work is an important aspect of this level of work, however the ending will follow a unique way for each client, with the both the therapist and client mutually experiencing the grief and celebration involved fully and together. My experience is that when a client is ready to leave therapy it is not a struggle to end. However, when the client is struggling to leave it invariably indicates more work to be done.







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Building the relationship – Five elements of how therapists foster a secure attachment - Daniel J. Siegel, “The Developing Mind” 1999 – Each pattern is the progressive articulation between me and not me. If disruption occurs during the time when a particular pattern is emerging, that pattern comes to dominate and does not assimilate into the whole. It does not produce a harmony and co-ordination between parts of the body and in relation. These elements build the therapeutic relationship fostering a secure attachment in the therapeutic work. 1. Collaboration

When the signals sent by each member of an attuned dyad are directly responsive in quality and timing with each other. A sharing of two minds at a basic level of primary emotion / resonant connection that may often have a sense of emerging vitality. To feel felt by the other.

2. Reflective Dialogue

Verbal sharing of a focus on the internal experience of each member of the dyad. Creating meaning. Such meaning-making, coupled with collaborative, reciprocal communication, allows the child to develop "mindsight” (The capacity of the mind to create the representation of the minds of others and of the self).

3. Repair In order to re-establish a lost connection within the dyad. Healing and teaches that misunderstandings happen and can be survived. 4. Coherent Narratives The connection of past, present and future is one of the core processes of the mind in the formation of the autobiographical form of self awareness. 5. Emotional Communication Sharing a sense of vitality and joy in living together with staying attached during uncomfortable emotions. Helping to understand and soothe painful emotional states. Includes the cycling need for direct connection and withdrawal. Building Rapport: Without rapport we are lost, this is often talked about as gaining a connection, being in relationship with, being attached to, however the key elements in gaining rapport are:

Matching

Pacing

Leading Matching & Pacing: This is mirroring the person you want to build rapport with:

Using their favoured representational systems … (Visual / kinaesthetic / Auditory, and from TA Feelings, thinking or Behaviours.).

Matching their natural rhythms, speech volume, breathing depth and speed.

Using their mannerism as an echo of them.

Reflecting back to them your experience of them. Leading: Going at the same pace as the client and gradually inviting / leading them in the therapeutic work. Contracts: A contact is an agreement between therapist and client to a defined course of actions and achievable sensory based outcomes. “A bi-lateral agreement to a well-defined course of action” – Berne 66







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The concept of contracting has evolved in recent years to allow a more organic growth of contracting in within psychotherapy practice. Charlotte Sills edited a book – “Contracts in TA psychotherapy and counselling” (2006) in which she presented a new model of contracting accounting for the reality that many clients are only partially aware of their desired outcomes when entering the therapeutic process: Therefore exploratory contracts leading to self-awareness, which then leads to more specific change objectives are now commonly used by therapists and coaches in their work with clients. The effectiveness of psychotherapy is associated with clarity having been achieved between client and therapist about what the purpose of the work is. Bordin (1994, cited in Hargaden and Sills 2002) researched the elements of effective psychotherapy and concluded that what is important is that ‘therapist and client have a clear shared agreement about the goal of their work and what will be the role of each party in the endeavor; and finally they will be linked by mutual respect and empathy. In traditional approaches to contracting a treatment contract will have visible verifiable outcomes and will look something like:

I will get a new job:

I will apply for new jobs until I get one:

I make this a two way process by agreeing what the client will do and what I will do as the therapist. The above contract contains both the outcome (a new job) and the action. Contracts and TA: Both the TA practitioner and the client agree stating the areas in which the client wishes to make changes and the outcomes expected. Contracts cover all areas of work… Administrative contracts: cover all the business side of contracting – when, where and how often and the cost of sessions for example. Sessional and Process contracts: Each session the TA coach / psychotherapist will contract for what the client wishes to address in this specific session as well as contracting within the ongoing process of the session: eg: “How about imagining your mother sitting on the sofa there and you telling her what you think / feel …” As the client responds to this suggestion the therapist and client are working contractually. Typical Contracting questions are:

What changes do you want / wish for in order to enhance your life?

How will you need to change to get what you want / wish for

What needs to happen for you to make this change?

What are you willing to do in order to make this change?

How might you sabotage yourself?

How will you and I know when you have made the change?

How will you reward yourself for making the change?

What will you do in your life after you have made the changes?







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(Adapted by Dave Spenceley TSTA from to M. James "Born to Win" ) Another effective series of questions:

1) What outcome do you expect from this process? 2) What will achieve if you get far more than you expect? 3) What will you do in order to achieve this outcome? 4) What do you expect others to do in order for you to achieve this outcome.

Contact > Contract > Content and Change work > Closure: This sequence describes the normal process of psychotherapy over many sessions as well as being reflected in each individual session and group. You make effective contact and establish the therapeutic relationship and space, then move to the contracting process, followed by the content of the client’s work, followed by closure. Steiner (1974) identified the following requirements for contracts – based on legal ideas.

Mutual consent - have the client and I mutually agreed a way of working, including payment, duration and time?

Valid consideration - am I being adequately recompensed for my skills and time?

Competency - am I sufficiently qualified and experienced to work with this client or do I need to refer them?

Non – Maleficience – No harm Sills’ contract matrix (2006) – This model revolutionized the approach to making contract within TA practice.

For a ‘behavioural outcome contract’ to be appropriate the client has a good understanding of what they want to achieve and how to achieve it

When a client knows what they want to change but does not know how to do it a ‘clarifying’ contract is appropriate.

Clarifying

Behavioural outcome – I know

what I want to change

Exploratory

Growth and discovery

No self understandi

ng

Hard, verifiable, sensory- based

Self understandi

ng

‘soft’, subjective, emergent







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An ‘exploratory contract’ provides a soft contract in which she develop and find out what it is that she does want.

Process contracts (Lee 1997, ed Sills 1997) ensure that the therapist remains attuned to the client moment by moment.

I developed a simplified picture for exploratory psychotherapy to simplify the picture:

>>> specified behavioural changes >> Current state: -----------------------------------------------------------------------------------------Self exploration and growth

>>> Specific areas of exploration >>> Linear Treatment plans from TA writers: Eric Berne: Four stages of Cure: (1961 TA psychotherapy in Action)

1. Social control: In this situation the client carries out the actions which were previously avoided. 2. Symptomatic relief: in which the client no longer feels the fear associated with the previous difficulty. 3. Transference cure: in which the client appears to reach autonomy, however this is only in response to

the transference with the therapist. 4. Script cure: in which the person reaches autonomy. (Is this possible? Yes for many difficulties but I

don’t think we ever actually self-actualise… not unless we are a saint or an eastern master?).

Berne’s 4 stages of the Treatment Sequence: 1. Structural Analysis 2. Transactional Analysis 3. Game Analysis 4. Script Analysis

Berne developed this theme in his writing to end with the following sequence:

1. Preliminary Phase:

Initial Interview

Business Contract 2. Script Analysis 3. Script Antithesis 4. Redecision:

Berne’s (1966) Therapeutic Operations: (See also Charlotte Sills and Helana Hargadens’s book… TA a Relational Therapy… where they have changed the name to empathic interventions and added an 9th intervention of holding)

1. Interrogation – Empathic inquiry (Asking questions) 2. Specification (Repeating what the client has said to clear it and to add more information) 3. Confrontation (Pointing out inconsistencies) 4. Explanations (The therapist says what they think is going on) 5. Illustrations (Metaphors etc) 6. Confirmations (Confirming the clients Adult thinking) 7. Interpretation (Aimed at deconfusing the Child ego state) 8. Holding Therapeutic holding within the relational therapeutic work.







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9. Crystallisation (Adult – Adult, bringing together all 3 ego states of the client preparing to make a redecision)

Ian Stewart (TA Counselling in Action) points out that treatment direction and planning is always based on the interplay between 3 aspects of the work:

1. The diagnosis 2. The contract 3. The choice of interventions, both long term and short term actions, noting the choice of attention to

both process and content. 4. I add to a further trio: The 3 P’s as: Crossman)

a. Potency b. Protection c. Permissions

Richard Erskine: Six Stages of Treatment: (TAJ July 1973) 1. Defensive 2. Anger 3. Hurt 4. Self as a Problem 5. Taking Responsibility 6. Parents are forgiven.

McCormick and Pulleyblank: 7 Stages of Redecision Therapy: Redecision Therapy expanded perspectives.

1. Contact 2. Contract 3. Exploration of Early transactions through experience. 4. Exploration of the early transactions and the decisions made 5. Exploration of advantages and disadvantages of staying with the early decision. 6. Redecision 7. Practicing the new decision.

Petruska Clarkson: TA Psychotherapy and Integrated Approach

1. Establishing a working relationship 2. Contracting 3. Decontamination (Adult ego state work) 4. Deconfusion (Child ego state work) 5. Establish an internal Nurturing Parent 6. Emotional fluency 7. Redecision work 8. Parent ego state work 9. Rechilding 10. Reorientation 11. Relearning 12. Termination

Woollams & Brown: Transactional Analysis

1. Motivation 2. Awareness







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3. Treatment Contract 4. Deconfusing the Child 5. Redecision 6. Relearning 7. Termination

The four rules of therapy: Always trust the process

The therapist should remain in an Ok position during and after therapy.

Deal with the structure of the relationship between therapist and client before dealing with the content of the contract.

Deal with the transference and counter transference issues before dealing with the content of the contract.

Deal with any here and now issues between the client and the therapist or other group members before dealing with the content of the contract….

TAJ reading list: Michele Novellino TAJ: July 1985 - Redecision analysis of transference; A TA approach to transference neurosis. Transference neurosis is discussed from a TA perspective. Mellor's (1980) developmental model of impasses is considered as a useful way to analyze transference and countertransference phenomena. Clinical examples are given and treatment planning is illustrated. William F. Cornell TAJ: Jan 1986 - Setting the therapeutic stage; The initial session. This article addresses the question of what we teach our clients - directly and indirectly about the nature of psychotherapeutic work through the process of the initial interview(s). Three central purposes for the initial interview are discussed: engaging the client in a mutual collaboration, establishing the therapeutic canon, and giving equal attention to assessing a client's strengths/competencies and difficulties. Notes on the clinical supervision of the initial interview are also included. Vann Joines TAJ: July 1988 - Diagnosis and treatment planning using a transactional analysis framework. Transactional analysis is an excellent tool for effective diagnosis and treatment planning. When integrated with the concepts of individuation and attachment, script types, and personality adaptations, the OK Corral (Ernst, 1971) offers clinicians a comprehensive diagnostic and treatment guide. When combined with contracting, the therapist and client together can formulate a treatment plan that is clear, direct, and enjoyable. Petruska Clarkson TAJ: July 1988 - Script Cure? A diagnostic pentagon in different types of therapeutic change: Although there are scattered references to different psychotherapy outcomes through-out Berne's work, nowhere does he bring them together for comparison, contrast, and confirmation; nor does he show how possible psychotherapy outcomes can be systematically identified and described. This article presents five possible outcomes: Script Cure, Making Progress, Disintegration, Disillusionment, and Counterscript Cure. These "faces of change" are discussed as five separate systems with their own frames of reference, including idiosyncratic motivations for seeking/avoiding future changes, characteristic response patterns, and differing capacities in managing stress. Each is associated with an archetypal or mythological image which may aid the psychotherapist in distinguishing, defining, and recognizing the five types of outcome so that he or she can facilitate life script changes that are genuine, stable under stress, and provide a fertile and resilient ground for future growth. A pentagon diagram summarizes these major points.







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Landy Gobes TAJ: Jan 1993. - C4P4 A consultation checklist: The C4P4 Checklist-(Contact, Contract, Context, Content, Process, Parallel process, Professional level of development, and Plan for the future)-is both an organizing technique and a memory aid for consultants. Consultation is differentiated from supervision and training. Keith Tudor TAJ: July 1995 - What do you say about saying goodbye? Ending Psychotherapy: This article identifies issues related to ending psychotherapy and suggests an addition to Berne's (1966) three methods of termination. Drawing on the professional literature concerning transactional analysis, dying, death, mourning, and bereavement, the author outlines seven tasks in the process of ending TA psychotherapy. Gordon Hewitt TAJ: July 1995 - Cycles of psychotherapy This article proposes a system for classifying psychotherapy, counseling, and supervision in terms of a cycle of four phases. The author describes each phase and the boundary condition that indicates the client is ready to move to the next phase, as well as the tasks of therapist and client at each phase. The effects of premature passage to the next phase of treatment or termination at an inappropriately early phase are also discussed. The phases, with their boundary conditions in brackets, are: contact (contract), content (decision or redecision), consolidation (integration), and conclusion (termination or reengagement).





TA and treatment planning for psychotherapists

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